basic hematology overview - tecnologos medicos
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Basic Hematology overview
Julia Fonseca BS, MT(ASCP), SCYM(ASCP), SH(ASCP)
Fonseca.julia56@gmail.com
Objectives Provide an overview of the clinical features of the most common hematologic
disorders.
Review of Erythrocytes
-Rbc count and morphology, RBC indices
-Haemoglobin, haematocrit
-Retic count and ESR
Diagnosis of anemias
Review WBC
-WBC count, morphology and differentials
-Acute leukemias and cytochemical stains
-Chronic leukemias
-Reactive disorders of granulocytes ,monocytes and lymphocytes
Review haemostasis: PTT, APTT, Fibrinogen, FDP, D- dimer
Review of haemoglobinopathies
Review of fluids
Hematology
Study of blood and blood forming tissues including the diagnosis, treatment, and prevention of diseases of the blood, bone marrow, and immunologic, hemostatic, and vascular systems
Key components of hematologic system are:
Blood
Blood forming tissues
Bone marrow
Spleen
Lymph system
Blood components and function
Delivery of nutrients
Oxygen
Food
Vitamins
Removal of wastes
Carbon dioxide
Nitrogenous wastes
Cellular toxins
Repair of its conduit
Protection versus invading microorganisms
Multiple cellular & acellular elements
Components
Plasma 55%
Blood Cells 45%
Erythrocytes/RBCs
Leukocytes/WBCs
Thrombocytes/Platelets
Red Blood Cells(Oxygen & CO2 transport)
Coagulation/platelets(Maintenance of vascular integrity)
White Blood Cells (Protection versus pathogens)
Hematopoiesis
In humans, occurs in bone marrow exclusively
All cellular elements derived from pluripotent stem cell (PPSC)
PPSC retains ability to both replicate itself and differentiate
Types of differentiation determined by the influence of various cytokines
Cytokines are a group of proteins secreted by cells of the immune system that act as chemical messengers. Cytokines released from one cell affect the actions of other cells by binding to receptors on their surface. Through this process, cytokines help regulate the immune response.
RED BLOOD CELLS
Normal - Anucleate, highly flexible biconcave discs, 80-100
femtoliters in volume
Flexibility essential for passage through capillaries
Major roles - Carriers of oxygen to & carbon dioxide away from
cells
ERYTHROPOIETIN
Cytokine - Produced in the kidney
Necessary for erythroid proliferation and differentiation
Absence results in apoptosis of erythroid committed cells
Anemia of renal failure 2° to lack of EPO
Nuclear signal sent to activate production of proteins leading
to proliferation and differentiation
Signal also sent to block apoptosis
RETICULOCYTE COUNT
Retic (% Reticulocytes) are immature red blood cells.
A reticulocyte count is a test used to measure the level of
reticulocytes in your blood
More accurate way to assess body’s response to anemia
Normal result for healthy adults who are not anemic is around
0.5% (0.005 × 10-3) to 2.5% (0.025 × 10-3).
Because the reticulocyte count is expressed as a percentage of total RBCs, it must be corrected according to the extent of anemia with the following formula:
Count a minimum of 1000 erythrocytes.
#of retics /1000 x 100=_________% uncorrected retics
absolute retics= # or uncorrected retics X RBC count
Corrected retics= retics% x hct patient/ hct mean normal
RPI= corrected retics%/ maturation time: >3 compensated bone marrow
RBC Assessment
Number - Generally done by automated counters, using impedance measures
Size - Large, normal size, or small; all same size versus variable sizes (anisocytosis). ( Microcyte, Macrocyte, Normocyte)
Shape - Normal biconcave disc, versus spherocytes, versus oddly shaped cells (poikilocytosis)
Polychromasia is a lavender-bluish color to RBC's due to RNA retained in larger, immature cells (macrocytes). They are associated with:
acute and chronic hemorrhage
hemolysis
neonates
treatment for anemia
Inclusion bodies are nuclear or cytoplasmic aggregates of stainable substance, usually proteins.
The inclusion bodies in red blood cells are almost always indicative of some sort of pathology, and thus it is useful to understand each inclusion body that can occur within a red blood cell
Dimorphic is a term used to describe two circulating red cell populations and the RDW will be >14%. These are associated with:
transfusion
myelodysplastic syndrome
vitamin B12, folate or iron deficiency
RBC indices
Red blood cell (RBC) indices are part of the complete blood count (CBC) test.
They are used to help diagnose the cause of anemia.
Mean corpuscular volume (MCV) is the average volume of a red blood cell and is calculated by dividing the hematocrit (Hct) by the concentration of red blood cell count.
A normal range for MCV is between 80 and 96 femtoliters per cell.
A low MCV indicates that the red blood cells are small, or microcytic.
Hemoglobin is the protein in your red blood cells that transports oxygen to the tissues of your body. MCH value is related to two other values, mean corpuscular volume (MCV) and mean corpuscular hemoglobin concentration (MCHC).
Together, MCH, MCV, and MCHC are sometimes referred to as red blood cell indices.
High RDW and low MCV. This suggests iron deficiency or
microcytic anemia.
High RDW and high MCV indicates a lack of B-12 or
folate. It can also suggest macrocytic anemia or chronic
liver disease.
High MCH scores are commonly a sign of macrocytic
anemia. This condition occurs when the blood cells are too
big, which can be a result of not having enough vitamin
B12 or folic acid in the body.
High MCH scores may also be the result of liver diseases
A low mean corpuscular hemoglobin concentration (MCHC)
shows that someone's red blood cells do not have enough
hemoglobin.
Given the following values, which set of red blood cell indices
suggests spherocytosis?
a) MCV 76 um ^ 3 MCH 19.9pg MCHC 28.5%
b) MCV 90 um ^ 3 MCH 30.5pg MCHC 32.5%
c) MCV 80 um ^ 3 MCH 36.5pg MCHC 39.0%
d) MCV 81 um ^ 3 MCH 29.0pg MCHC 34.8%
The correct answer is C: Spherocytes have a decreased cell diameter and
volume, which results in loss of central pallor and discoid shape. The index
most affected is the MCHC, usually being in excess of 36%.
Manual Cell Counting With Neubauer Chamber
The ruled area is 3mm2 divided into 9 large squares each with a 1
mm2 area. The large central square (which can be seen in its entirely with the
10X objective), is divided into 25 medium squares with double or triple lines.
Each of these 25 squares are is again divided into 16 small squares with
single lines, so that each of the smallest squares has an area of 1/400 mm2.
The glass cover is a squared glass of width 22 mm. The glass cover is placed
on the top of the Neubauer chamber, covering the central area. The ruled
area is 0.1 mm lower than the rest of the chamber. So that when a cover slip
is kept on the counting region, there is a gap of 0.1 mm (1/10mm) between
the cover slip and the ruled area.
WBC Counting Area
The four large squares placed at the corners are used for white blood cell count.
Since their concentration is lower than red blood cells a larger area is required to
perform the cell count.
RBC Counting Area
The large center square is used for RBC counts. This area is subdivided into 25
medium squares, which in turn are each divided into 16 squares. Of the 25 medium
squares, only the four corner squares and the center square within the large center
square are used to perform RBC counts.
Platelet Counting Area
The large center square is used to count platelets. Platelets in all 25 squares within
the large center square are counted.
The dilution factor used in the formula is determined by the blood
dilution used in the cell count. The depth used in the formula is
always 0.1. The area counted will vary for each type of cell count
and is calculated using the dimensions of the ruled area.
Example :
calculate total WBC count by using Neubauer counting chamber.
Number of cells counted = N = 150 (suppose)
Area Counted = 1 mm2 x 4 = 4 mm2 (area of four large corner squares)
Depth = 1/10 mm
Dilution = 1:20
Hence WBC/Cubic mm of Whole Blood = N x 50 = 150 x 50 = 7,500
Osmotic fragility test
In the osmotic fragility test, whole blood is added to varying
concentrations of NaCl and allowed to incubate at room temperature.
The amount of hemolysis is then determined by examining the
supernatant fluid either visually or with a spectrophotometer.
If erythrocytes are placed in an isotonic solution (0.85%) of NaCl, water
molecules will pass in and out of the membrane in equal amounts.
In hypotonic solutions, erythrocytes will hemolyze because more water
molecules enter into the cell than leave. This net influx of water molecules
eventually ruptures the cell membrane.
The main factor in this procedure is the shape of the erythrocyte, which is
dependent on the volume, surface area and functional state of the
erythrocyte membrane.
A spherocyte erythrocyte ruptures much more quickly than normal
erythrocytes, such as sickle cells and target cells.
The clinical value of the procedure is in differentiating various types of
anemia.
Osmotic fragility test
Decreased fragility:
-HbC disease
-Iron deficiency anemia
- Sickle cell anemia
- Thallasemia major
- Polycythemia Vera
-Hereditary spherocytosis
Increased fragility:
Acquired autoimmune hemolytic anemia
Burns
Chemical poisons
Hemolytic disease of the newborn
Sedimentation Rate
Sed rate, or erythrocyte sedimentation rate (ESR), is a blood test that can
reveal inflammatory activity in your body.
A sed rate test isn't a stand-alone diagnostic tool, but it can help your doctor
diagnose or monitor the progress of an inflammatory disease.
The sed rate test measures the distance red blood cells fall in a test tube in
one hour.
The farther the red blood cells have descended, the greater the inflammatory
response of your immune system.
Sed rate tests might be useful when evaluating unexplained fever, some
types of arthritis and symptoms that affect your muscles. Also, they can help
confirm a diagnosis of certain conditions, including:
Giant cell arteritis
Polymyalgia rheumatica
Rheumatoid arthritis
The normal range is 0-22 mm/hr for men and 0-29
mm/hr for women.
ANEMIA
Anemia is a condition with not enough red blood cells to carry
adequate oxygen to the body's tissues. Having anemia may
make you feel tired and weak.
Causes:
Your body doesn't make enough red blood cells
Bleeding causes you to lose red blood cells more quickly than
they can be replaced
Your body destroys red blood cells
Blood loss
Decreased production of red blood cells (Marrow failure)
Hemolysis
Distinguished by reticulocyte count
Decreased in states of decreased production
Increased in destruction of red blood cells
RBC DESTRUCTION - EXTRAVASCULAR
Heme metabolized to bilirubin in macrophage; globin metabolized
intracellularly
Unconjugated bilirubin excreted into plasma & carried to liver
Bilirubin conjugated in liver &excreted into bile & then into upper GI
tract
Conjugated bilirubin passes to lower GI tract & metabolized to
urobilinogen, which is excreted into stool & urine
RBC DESTRUCTION - INTRAVASCULAR
Free Hemoglobin in circulation binds to haptoglobin, yielding
low plasma haptoglobin
Hemoglobin filtered by kidney and reabsorbed by tubules,
leading to hemosideinuria
Capacity of tubules to reabsorb protein exceded, yielding
hemoglobinuria
Classification of anemia
Decreased production vs. RBC loss (increased destruction or bleeding)
RBC Size: (Macrocytic vs. microcytic vs. normocytic)
Hemoglobin Content:((Hypochromic vs. normochromic)
Shape: Normal or abnormal
Laboratory tests needed for anemia diagnosis
MCV, MCH, MCHC
RDW
Rbc count
Hemoglobin
Reticulocyte count
Occult blood
Direct antibody test
Peripheral Smear
Transferrin
Fe & TIBC
Ferritin
Vitamin B12 & Folate
Hemoglobin electrophoresis (Hgb A2 levels)
Bone marrow aspirate
Classification of anemia based on red blood cell size
HEMOLYTIC ANEMIA
Test Result
Reticulocyte Count Increased
Unconjugated Bilirubin Increased
Lactate Dehydrogenase Increased
Haptoglobin Decreased
Urine Hemoglobin Present
Urine Hemosiderin Present
Hemoglobinopathies/Thalassemia
Hemoglobinopathy is a group of rare, inherited disorders involving inherited
mutation of the globin genes leading to a qualitative or quantitative abnormality of
globin synthesis.
Structural hemoglobinopathy(qualitative)
Amino acid substitution in the globin chain
471 variants
The Thalassemias(quantitative)
Syndromes in which the rate of synthesis of a globin chain is
reduced.
Beta thalassemia reduced beta chain synthesis
Alpha thalassemia reduced alpha chain synthesis
CBC (complete blood count)
the number, size and shape of the red blood cells present.
how much hemoglobin is in RBC
MCV (mean corpuscular volume) is a measurement of the size of the
red blood cells.
A low MCV is often the first indication of thalassemia.
If the MCV is low and iron deficiency has been ruled out, the person may be a thalassemia trait carrier or have one of the hemoglobin variants that cause microcytosis
Blood smear of hemoglobinopahty
Microcytic
Hypochromic
Varying in size (anisocytosis) and shape (poikilocytosis)
Have uneven hemoglobin distribution (producing “target cells”
Detection of hemoglobin variants
These tests identify the type and measure the relative amount of hemoglobins.
hemoglobin electrophoresis
isoelectric focusing,
or high-performance liquid chromatography.
These techniques separate different hemoglobins based on their charge.
The relative amounts of any variant hemoglobin detected can help to
diagnose combinations of hemoglobin variants and thalassemia.
DNA analysis
This test is used to investigate deletions and mutations in the alpha
and
beta globin producing genes.
Family studies can be done to evaluate carrier status and the types
of mutations present in other family members.
DNA testing is not routinely done but can be used to help diagnose
hemoglobin variants, thalassemia, and to determine carrier status.
https://medquizzes.net/mcqs-hemoglobinopathies-and-
thalassemias-quizzes/
Hemoglobin electrophoresis
Hemoglobin E
2 nd most prevalent hemoglobin variant – 30,000,000 world wide
80% in Southeast Asia
Hb E trait: microcytosis (mean MCV=65fl).
No anemia
Hb E disease: MCV =55-65fl with minimal anemia
On HPLC has similar migration pattern as Hb A2 H
Hemoglobin C
Mutation in β-globin gene β(6glu->lys)
Seen predominantly in blacks: Gene prevalence in US black population is 2 to 3%
May confer malaria resistance
Often asymptomatic, mild anemia, splenomegaly
Blood smear shows many target cells, rare intracellular crystals
Hb S/C disease causes moderate to severe anemia and hemolysis
Laboratory Testing
Initial testing – CBC with peripheral smear
Polychromasia, spherocytes, schistocytes, sickle cells, Heinz bodies, basophilic
stippling; however, the lack of any of these cells does not rule out hemolytic anemia
Many hemoglobinopathies can be diagnosed using electrophoretic or high-
performance liquid chromatography (HPLC) techniques
Genetic testing
Sickledex test (Screening test)
Deoxygenated Hb-S is insoluble in a concentrated phosphate buffer solution and
forms a turbid suspension
Normal Hemoglobin A and other hemoglobins remain in solution
It does not differentiate between Sickle Cell Disease (S/S) and Sickle Cell Trait
(A/S)
Alkaline hemoglobin electrophoresis migration( ph=8.4)
C, A2, E, O
S, D, G
F alone
A alone
Acid hemoglobin electrophoresis migration (ph=6.0-6.2)
A,D, G, E,O together
S alone
F alone
C alone
Isopropanol stability test- to detect unstable hemoglobin
Alkali denaturation test for fetal hemoglobin- measures fetal hemoglobin
Solubility test for sickle cell-screen for sickle cell trait, differentiate HgS from HgD, Hgb C Harlem
Acid elution test(Kleihauer-Betke)- differentiate HPFH from other states with hgb F increased
Thalassemia
A single deletion (α-thalassemia minor)
silent carrier state – RBC morphology and hemoglobin
concentrations are usually normal
Two gene deletion (α-thalassemia minor)
Mild microcytic anemia
Three gene deletion (hemoglobin H disease)
Patients have moderate anemia, marked microcytosis,
splenomegaly, and bone marrow erythroid hyperplasia
Four gene deletion (Hydrops fetalis)
Not compatible with life. Hemoglobin is primarily comprised of γ4
(Bart’s), which has a very high affinity for O2 and is a poor oxygen
transporter
Clinical Significance of Beta-Thalassemia
Heterozygous asymptomatic •
Homozygous β0 is a severe disorder associated with transfusion
dependent hemolytic anemia
Homozygous B + is a heterogenous disorder –
severity depending on mutation and % of HbA
Increased HbA = decreased severity
Sickle cell anemia
Single nucleotide base change codes for valine instead of glutamic acid at the 6th
position from the N-terminus of the ß-globin chain
Affects the shape and deformability of the red blood cell
Leads to veno-occlusive disease and hemolysis
Which of the following electrophoretic results is consistent with a
diagnosis of sickle cell trait?
a) Hgb A: 40% Hgb S: 35% Hgb F: 5%
b) Hgb A: 60% Hgb S: 38% Hgb A2: 2%
c) Hgb A: 0% Hgb A2: 5% Hgb F: 95%
d) Hgb A: 80% Hgb S: 10% Hgb A2: 10%
The correct answer is: B: electrophoresis at alkaline ph usually shows 50-
70% Hgb A, 20-40% Hgb S, and normal levels of Hgb A2 in a patient with
the sickle cell trait.
Normal peripheral blood cells
Normal mature lymphocytes
Normal eosinophil
Normal basophil
Normal mature platelets
Neutropenia vs Neutrophilia
Neutropenia can be inherited or acquired.
Neutropenia usually results from decreased production of
neutrophil precursor cells in the marrow
Neutrophilia is an increase in the absolute neutrophil count to
a concentration greater than two standard deviations above
the normal population mean value.
Monocytosis
Monocytosis is an increase in the number of monocytes circulating in the
blood.
Monocytes are white blood cells that give rise to macrophages and
dendritic cells in the immune system.
High levels of monocytes may indicate the presence of chronic infection,
an autoimmune or blood disorder, cancer, or other medical conditions.
This condition is a normal immune response to an event, such as
infection, injury, inflammation, some medications, and certain types of
leukemia.
Normal value of Monocytes - 0.2–1.0×109/l (2–10%)
Lymphocytopenia vs Lymphocytosis
Lymphocytopenia is the condition of having an abnormally low level of
lymphocytes in the blood.
The opposite is lymphocytosis, which refers to an excessive level of
lymphocytes.
Lymphocytosis is a feature of certain infections, particularly infections in
children. It may be especially marked in pertussis, infectious mononucleosis,
cytomegalovirus infection, infectious hepatitis, tuberculosis and brucellosis
Elderly patients with lymphoproliferative disorders, including chronic
lymphocytic leukaemia and lymphomas, often present with
lymphadenopathy and a lymphocytosis.
Normal bone marrow cells
Blood cells are made in the bone marrow.
Bone marrow is the soft inner part of some bones, like the skull, shoulder
blades, ribs, pelvis, and backbones.
Bone marrow is made up of:
A small number of blood stem cells
More mature blood-forming cells
Fat cells
Supporting tissues that help cells grow
Inside the bone marrow, blood stem cells divide and mature to make new
blood cells.
During this process, the cells become either lymphocytes (a kind of white
blood cell) or other blood-forming cells. These other blood-forming cells
mature into red blood cells, white blood cells (other than lymphocytes), or
platelets.
Normal bone marrow cells
Red blood cells carry oxygen from the lungs to all other tissues in the body,
and take carbon dioxide back to the lungs to be removed.
Platelets are actually cell pieces made by a type of bone marrow cell called
the megakaryocyte. Platelets are important in plugging up holes in blood
vessels caused by cuts or bruises.
White blood cells help the body fight infections. Having too few white blood
cells (neutropenia) lowers your immune system.
The percentage of blast cells. Blasts are normally 1 to 5 percent of marrow
cells. Having at least 20 percent blasts is generally required for a diagnosis
of AML.
Normal bone marrow cells
Lymphocytes are mature, infection-fighting cells that develop from lymphoblasts, a
type of blood stem cell in the bone marrow.
Lymphocytes are the main cells that make up lymphoid tissue, a major part of the
immune system. Lymphoid tissue is found in lymph nodes, the thymus gland, the
spleen, the tonsils, and adenoids. It's also scattered throughout the digestive and
respiratory systems and the bone marrow.
The 2 main types of lymphocytes are:
B lymphocytes (B cells) protect the body from invading germs by
developing (maturing) into plasma cells, which make proteins called antibodies.
The antibodies attach to the germs (bacteria, viruses, and fungi), which helps other
white blood cells called granulocytes recognize and destroy them. B lymphocytes
are the cells that most often develop into chronic lymphocytic leukemia (CLL) cells.
T lymphocytes (T cells) can recognize cells infected by viruses and
directly destroy these cells. They also help regulate the immune system.
Normal bone marrow:
Granulocytes are mature, infection-fighting cells that develop from
myeloblasts. Granulocytes have granules in them that contain enzymes and
other substances that can destroy germs, such as bacteria(neutrophils,
basophils, eosinophils)
Monocytes develop from blood-forming monoblasts in the bone marrow and
are related to granulocytes. After circulating in the bloodstream for about a
day, monocytes enter body tissues to become macrophages. Macrophages
also help lymphocytes recognize germs and start making antibodies to fight
them.
Normal megakaryocyte
Normal mature Plasma cell
Leukemia/Lymphoma
Definition of leukaemia:
Cancer that starts in blood-forming tissue, such as the bone marrow and
the lymphatic system and causes large numbers of abnormal blood cells to
be produced and enter the bloodstream.
Mature and immature leukemia classification
Myeloid and Lymphoid leukemias
Mature B and T lymphoid neoplasm
Leukemia is cancer of the body's blood-forming tissues, including the bone marrow and the lymphatic system.
Many types of leukemia exist. Some forms of leukemia are more common in children. Other forms of leukemia occur mostly in adults.
Leukemia usually involves the white blood cells. Your white blood cells are potent infection fighters — they normally grow and divide in an orderly way, as your body needs them. But in people with leukemia, the bone marrow produces abnormal white blood cells, which don't function properly.
Treatment for leukemia can be complex — depending on the type of leukemia and other factors. But there are strategies and resources that can help to make your treatment successful.
Leukemia symptoms
Leukemia symptoms vary, depending on the type of leukemia.
Common leukemia signs and symptoms include:
Fever or chills
Persistent fatigue, weakness
Frequent or severe infections
Losing weight without trying
Swollen lymph nodes, enlarged liver or spleen
Easy bleeding or bruising
Recurrent nosebleeds
Tiny red spots in your skin (petechiae)
Excessive sweating, especially at night
Bone pain or tenderness
How leukemia forms
In general, leukemia is thought to occur when some blood cells acquire
mutations in their DNA.
Certain abnormalities cause the cell to grow and divide more rapidly and to
continue living when normal cells would die.
Over time, these abnormal cells can crowd out healthy blood cells in the bone
marrow, leading to fewer healthy white blood cells, red blood cells and platelets,
causing the signs and symptoms of leukemia.
Leukemia classification
Doctors classify leukemia based on its speed of progression and the type of cells
involved:
Acute leukemia: In acute leukemia, the abnormal blood cells are immature
blood cells (blasts).
Chronic leukemia: Chronic leukemia involves more mature blood cells
The second type of classification is by type of white blood cell affected:
Lymphocytic leukemia. This type of leukemia affects the lymphoid cells
Myelogenous leukemia. This type of leukemia affects the myeloid cells.
Myeloid cells give rise to red blood cells,
white blood cells and platelet-producing cells.
The major types of leukemia are:
Acute lymphocytic leukemia (ALL). This is the most common type of leukemia in
young children. ALL can also occur in adults.
Acute myelogenous leukemia (AML). AML is a common type of leukemia. It
occurs in children and adults. AML is the most common type of acute leukemia in
adults.
Chronic lymphocytic leukemia (CLL). With CLL, the most common chronic adult
leukemia, you may feel well for years without needing treatment.
Chronic myelogenous leukemia (CML). This type of leukemia mainly affects
adults. A person with CML may have few or no symptoms for months or years
before entering a phase in which the leukemia cells grow more quickly.
Other types. Other, rarer types of leukemia exist, including hairy cell leukemia,
myelodysplastic syndromes and myeloproliferative disorders.
Immature cells in leukemia
In healthy bone marrow, blood-forming cells known as hematopoietic stem
cells develop into red blood cells, white blood cells, and platelets through a
process called hematopoiesis.
Hematopoiesis occurs throughout your entire lifespan. The stem cell chooses
its path of development into one of two cell lines, the lymphoid cell line or
the myeloid cell line.
In the myeloid cell line, the term "blast cell" refers to myeloblasts or myeloid
blasts. These are the very earliest and most immature cells of the myeloid cell
line.
Myeloblasts give rise to white blood cells. This family of white blood cells
includes neutrophils, eosinophils, basophils and monocytes, and
macrophages.
Blast cell
Blasts are precursors to the mature, circulating blood cells such as
neutrophils, monocytes, lymphocytes and erythrocytes. Blasts are usually
found in low numbers in the bone marrow. They are not usually found in
significant numbers in the blood.
Common site for the bone marrow aspiration and biopsy in an
adult
Blast morphology
Blasts are cells that have a large nucleus, immature chromatin, a prominent nucleolus, scant cytoplasm and few or no cytoplasmic granules.
Cell size - blasts are often medium to large cells. They are usually larger than a lymphocyte and at least the size of a monocyte.
Large nucleus - most of the cell is taken up by the nucleus (a high nuclear to cytoplasmic ratio).
Immature chromatin - the nuclear chromatin looks as if it composed of fine dots. One can visualize this chromatin as many tiny points made by the tip of a sharp pencil on a piece of paper. Monocyte chromatin is more linear and dark, looking like smudged pencil lines. Lymphocyte chromatin looks to be colored in heavy crayon.
Prominent nucleolus.
Conformable nuclear membrane - the nuclear membrane often conforms to the shape of the cytoplasmic membrane. The nucleus appears squishy. A lymphocyte nucleus appears rigid.
Few to no cytoplasmic granules
Auer rods - orange-pink, needle-like cytoplasmic structures in blasts of myeloid lineage. These may be numerous in acute promyelocytic leukemia. 20% of more blasts in the peripheral blood or bone marrow
Acute Myeloid Leukemia
Diagnosis in bone marrow evaluation: 20% or more of blasts
Hypercellular
Predominance of blasts: medium size to large with moderate to abundant variably basophilic cytoplasm that may contain few azurophilic granules
Auer rods present in 60=70% of cases
Nuclear shape varies: round to irregular or convoluted
Chromatin : dispersed with one or more nucleoli
Retarded maturation
Dysplastic changes in granulocytic, erythroid and megakaryocytic precursors
Normal maturation of WBC: granulopoiesis
Auer rods present in AML
Auer rods (see arrow in image) are cytoplasmic inclusions which result from an
abnormal fusion of the primary (azurophilic) granules.
Auer rods may be seen in myeloblasts, promyelocytes and monoblasts, but are not
seen characteristically in lymphoblasts
Undifferentiated acute myeloblastic
leukemia
AML without maturation(M0) 10% of cases of AML
The sum of myeloblasts must be 90% or more of the non-erythroid cells in the bone
marrow.
Blasts may be MPO or SBB positive.
Immunophenotyping studies recommended(Flow Cytometry)
Blood: leukopenia with occasional myeloblasts or marked leukocytosis with 100% of
blasts.
There is anemia, neutropenia and thrombocytopenia(blood)
In bone marrow is hypercellular with predominance of blasts; erythroid and
megakaryocyte precursors are markedly decreased.
The blast nucleus is round but may show irregularity in some cases; nucleoli are
variably prominent.
Auer rods may be found in 50% of cases.
Evidence of maturation to promyelocytes is absent.
Diagnose at any age with a median of 45-50 years.
AML with maturation(M1)
The most common of AML; 30-45% of the cases.
It has maturation beyond myeloblasts.
The sum of myeloblasts is from 20-89% of non-erythroid cells; granulocytes to
mature neutrophils are more than 10% of cells and monocytes less than 20%.
Auer rods are present.
Dysplastic mature neutrophils, erythroid and megakaryocyte precursors.
MPO positive; chromosome abnormalities found: example: t
(6;9)(p23;q34);DEK/CAN(maturation with a basophil component)
Occurs at any age: median 45-50years.
Prognosis variable.
Acute promyelocytic leukemia M3
T15;17
Leukocyte count decreased in typical hyper granular APL
Has numerous red to purple cytoplasmic granules, they obscure the nuclear borders
Associated to DIC; MPO positive, non-specific esterase weakly positive
Sometimes has deeply basophilic cytoplasm; Auer rods present
Nucleus: kidney shape or bilobed; cytoplasm with coalescent large granules(bright
pink)
Myeloblasts are minor component
In microgranular variant: leukocyte count is elevated, fine granulation and markedly
irregular nuclei; confused with acute monocytic leukemia
Increased side scatter pattern, lack expression of Hla-Dr and Cd 34, weak Cd 117
Breakpoint on band q22 of chromosome 15 and on band 12 at the first intron of the
retinoic acid receptor alpha (RARalpha) gene on chromosome 17.
Remission with ATRA
APL hypogranular variant
Acute Myelomonocytic Leukemia(M4)
Accounts for 15-25% of AML.
The sum of myeloblasts, monoblasts and promonocytes is 20% or more; 20-79% of
bone marrow cells are monocyte lineage.
Non-specific esterase is positive.
The diagnosis of AMML is if the blood monocyte count exceeds 5 x 103/mm3.
Auer rods present; there are no specific cytogenetic abnormalities, some cases are
inv(16) or 11q23.
Occurs in both children and adults( 50 years).
Wbc elevated, organomegaly, lymphadenopathy and other tissue infiltration are
common.
Treatment response and survival varies.
Acute Monoblastic and Monocytic leukemia(M5)
Account for 8% of AML.
80% or more of the non erythroid cells in the bone marrow are monoblasts,
promonocytes and monocytes.
In acute monoblastic leukemia 80% or more of the monocytic cells are monoblasts.
In acute monocytic leukemia less than 80% of the monocytic cells are monoblasts.
In acute monoblastic leukemia, blasts are large with abundant basophilic cytoplasm
with fine peroxidase negative granules; auer rods are not observed; the nucleus is
round with reticular chromatin and one or more nucleoli.
Monoblasts are non-specific esterase positive and MPO negative.
M5-monocytic leukemia
Acute erythroid leukemia(M6)
5% of AML
2 subtypes: erythroid/myeloid and pure erythroid
In erythroid/myeloid erythroblasts are 50% or more; 20% or more are
myeloblasts. Dyserythropoiesis is prominent. It presents with pancytopenia
and NRBC in blood. There is erythroid hyperplasia, dyserythropoiesis,
megaloblastoid changes, karyorrhexis. Multiple nuclei are common.
Vacuoles may be present. PAS positive. Auer rods are present in
myeloblasts.
In pure erythroid leukemia, blasts are all erythroid.
Primarily in adults of advance age. Evolve from MDS. Prognosis is poor.
M6 Erythroid Leukemia
M7 leukemia
AML showing maturation in the megakaryocyte lineage and small and large
megakaryoblasts.
Most commonly in infants without Down Syndrome with a female predominance.
De novo, restricted to infants and young children(3 years or less)
Organomegaly, patient with anemia, thrombocytopenia and elevated WBC cell
count.
Morphology and cytochemistry similar to megakaryoblastic leukemia of AML(M7)
SBB and MPO are negative.
MPO negative; Cd 41, Cd61 positive expression
FAB /WHO classification of acute lymphoblastic
leukemia
Acute lymphoblastic leukemia (L1/L2)
Precursor B cell
Precursor T cell
Acute lymphoblastic leukemia, B-cell (L3)
(equivalent to Burkitt Iymphoma in leukemic phase)
Biphenotypic
FAB classification
ALL-L1: small uniform cells
ALL-L2: large varied cells
ALL-L3: large varied cells with vacuoles (bubble-like features
Flash cards to study leukemia
https://www.cram.com/flashcards/acute-leukemias-6033326
Cytochemical stains for leukaemia
MPO
SBB
Specific Esterase: Naphthol As-D Chloroacetate esterase
Non-specific esterase:Alpha naphthyl butyrate esterase; alpha naphthyl
acetate
Oil O-Red
Toluidine Blue
PAS
Trap
Cytochemical stains
Myeloperoxidase(MPO): Peroxidase is present in primary granules of neutrophils and
in granules of eosinophils and monocytes The identification of this enzyme in the
cytoplasm of leukocytes is used to: distinguish acute myelogeneous
leukemia(AML)from acute lymphocytic leukemia (ALL)
Sudan Black B staining: Stains a variety of lipids, including neutral fat,
phospholipids, and sterols.
Periodic Acid Schiff (PAS) oxidizes carbohydrates, glycogen and similar
compounds to aldehydes In ALL lymphoblasts show variability: 50% of cases contain
coarse granules or large blocks of PAS positive material. A coarse diffuse satin is
characteristic of ALL L1 and L2 are positive but not L3. In M6, the reaction of
erythrocytic precursors is intense In M7, the blast cells usually show a diffuse and
granular positive reaction
Esterase staining: represents a series of different enzymes acting upon select
substrates. Distinguish granulocytes from monocytes Naphthol As-D Chloroacetate
esterase: specific for cells of granulocytic lineage Alpha-naphtyl acetate esterase:
detected primarily in monocytes, macrophages and histocytes Alpha-naphtyl acetate
esterase with fluoride inhibition: all monoblasts will be negative for enzyme activity
Non specific esterase: Alpha naphthyl butyrate esterase: this stain is positive in cells
from the monocyte and megakaryocyte series. This stain is most commonly used to
confirm a diagnosis of acute myelogenous leukemias with monocytic differentiation.
Oil O red stain used for staining of neutral triglycerides and lipids on frozen sections
and some lipoproteins on paraffin sections. Neutral lipids may be present in some
lymphomas, especially in Burkitt’s lymphoma and large cell lymphoma Leukemic
lymphoblasts contain ORO positive inclusions. Myeloblasts are negative
Toluidine Blue Stain reacts with the acid mucopolysaccharides in human blood cells
Marker for basophilic leukemia and systemic mast cell disease
Acid Phosphatase resistant leukocytes TRAP stain most of the acid phosphatase
isoenzyme is inhibited by l-tartaric acid. The cells of hairy cell leukemia, Sezary
syndrome and some T cell acute lymphoblastic leukemia are tartrate
resistant(positive reaction).
Identification of leukemias by Flow Cytometry
Flow cytometry is a technique used to detect and measure physical and chemical
characteristics of a population of cells or particles.
The basic principle of flow cytometry is the passage of cells in single file in front of a
laser so they can be detected, counted and sorted. Cell components are
fluorescently labelled and then excited by the laser to emit light at varying
wavelengths.
Flow Cytometry
Antibodies used in immunotyping/Cytometry
Blasts antibodies used in immunotyping
myeloid—CD 34, MPO,Cd235a, Cd117
lymphoid—CD 10, TDT, kappa or Lambda light chain
monoclonality, Cd34+/- Cyto cd3 or Cd79a
Myeloid(neutrophils & monos)-normal mature
Cd13,33,14,15,64
Lymphoid- normal mature
Lymph T- Cd2,3,4,5,7,8
Lymph B- Cd19,20,22,25 Kappa & Lambda light chain
NK lymphs-Cd3-/Cd56+/Cd16+
Plasma cell-
Cd138+/38+/56+, Cd19/cd20, Kappa or Lambda
Ancillary tests
Cytogenetics : usedto look for changes in chromosomes
Fish molecular testing method uses fluorescent probes to
evaluate genes and/or DNA sequences on chromosomes.
PCR is a laboratory method used for making a very large number of copies of short
sections of DNA from a very small sample of genetic material. This process is called
"amplifying" the DNA and it enables specific genes of interest to be detected or
measured.
Chronic Leukemias
In CML, a genetic change takes place in an early (immature) version of myeloid cells
-- the cells that make red blood cells, platelets, and most types of white blood cells
(except lymphocytes).
This change forms an abnormal gene called BCR-ABL, which turns the cell into a
CML cell.
The leukemia cells grow and divide, building up in the bone marrow and spilling over
into the blood.
In time, the cells can also settle in other parts of the body, including the spleen.
CML is a fairly slow growing leukemia, but it can change into a fast-growing acute
leukemia that's hard to treat.
In chronic leukemia, the cells mature partly but not completely.
They generally do not fight infection as well as normal white blood cells do.
Chronic leukemias can take a long time before they cause problems, and most
people can live for many years.
Chronic leukemias are generally harder to cure than acute leukemias.
Chronic Leukemias
Myeloproliferative neoplasm:
Chronic myelogeneous leukemia(BCR/ABL1)
Chronic neutrophilic leukemia
Chronic eosinophilic leukemia, nos
Chronic basophilic leukemia
Myelodysplastic/myeloproliferative
Chronic myelomonocytic leukemia
Juvenile myelomonocytic leukemia
Chronic lymphoid leukemia
Chronic lymphocytic leukemia: B or T cell origin
B-cell prolymphocytic leukemia
Hairy Cell leukemia
T-cell prolymphocytic leukemia
T-cell large granular lymphocytic leukemia
Aggressive NK cell leukemia
Adult T-cell Leukemia/Lymphoma
Sezary Syndrome
Coagulation
Haemostasis mechanismMaintains blood in the fluid state within the blood vessels
Prevents excessive blood loss after vascular injury
Vascular damage: blood clots to seal vessel: includes vascular constriction,
platelet aggregation, and fibrin formation
Clot has formed, tissue repaired- fibrinolysis began(digestion of the clot) initiated by trauma to vessel : vasoconstriction(reduce blood flow), platelets adhere to subendothelial collagen fibers and micro fibrils, tissue factor(in the vessel) initiate coagulation.
Generation of thrombin converts fibrinogen to fibrin incorporated in the platelet plug
Stable clot formed(cross-linked fibrin strands by factor XIIIa and contraction of platelet mass.
Note: white thrombus: formed in arterial system, primarily of platelets
red thrombus: found in venous circulation erythrocytes and platelets
Platelets
anucleated disc-shaped cytoplasmic fragments(2-4um)
blue gray cytoplasm and purplish granules
formed in bone marrow by megakaryocytes
9-10 days in circulation , some sequestered in the splenic pool
contains 3 types of secretory granules: lysosomes
containing acid hydrolases; alpha granules containing
platelet factor 4, and beta-thromboglobulin, platelet
derived growth factor and coagulation proteins found in
plasma( fibrinogen and von Willebrand factor); and delta
granules containing ADP, ATP, Ca, serotonin.
Primary hemostasis begins with adhesion of platelets.
Adhesion begins when von Willebrand factor binds to subendothelial receptors and to
glycoprotein 1b on platelets).
Collagen induces platelets to aggregate by stimulating then to secrete ADP and to
synthesize thromboxane A2.
ADP amplifies aggregation.
Thrombin formed by the soluble coagulation system also activates platelets.
Vasoconstriction is enhanced by the release of serotonin and thromboxane A2.
Platelet activation induces expression of binding sites for coagulation proteins(platelet
factor 3).
Adhesion and aggregation of platelets occur mediated by fibrinogen which links 2
platelets by the fibrinogen receptor (glycoprotein IIb-IIIa).
The platelet plug is provisional unless a firm fibrin clot forms around it. Platelet
actomyosin provides for clot retraction and consolidation.
2nd phase of hemostasis
-soluble plasma fibrinogen is converted to an insoluble
fibrin clot
-enzymatic pathways (zymogen , enzyme precursor)
initiated by 2 mechanism of vitamin k-dependent proteins:
procoagulant (factor II,VII, IX,X)
anticoagulant(protein C and protein S)
Clots requires plasma coagulation proteins (4 categories):
1) serine endopeptidases (proteases): Factors
II,VII,IX,X,XII and pre-kallikrein circulate in the zymogen
form. Factors VII,IX,X requires vitamin K to synthesize
active coagulation proteins that binds with Calcium ions.
2)cofactors: required for activation of some of the
procoagulant proteins: High Molecular Weight kininogen,
factors V, VIII
3)fibrinogen: Factor I (soluble protein) becomes
insoluble fibrin clot following cleveage by thrombin
4)factor XIII: is a plasma transglutaminase that
activated stabilizes the fibrin clot
Activation of coagulation: 2 mechanismExtrinsic(PT):
Tissue factor initiates the pathway (skin, brain, lung, placenta, monocytes, in
the vessels) forming a complex with factor VIIa.
This complex activates factor X; factor Xa in the presence of cofactor (Va),
activates prothrombin to form thrombin.
Excessive activity is regulated by tissue factor pathway inhibitor.
Prothrombin activation occurs on cellular surface of platelets, endothelial cells,
smooth muscle cells, and monocytes, and requires Ca and factor Va.
Once thrombin is formed, clotting occurs. Polymerization of fibrin monomers
and cross-linking of fibrin by thrombin-activated factor XIIIa lead to an insoluble
fibrin clot.
Intrinsic pathway: APTTExposition to collagen (subendothelial connective tissue) activate
factor XII.
Factor XIIa converts prekallikrein to kallikrein, which convert
more factor XII to factor XIIa which in turn activates factor XI.
This requires the cofactor protein HMW kininogen.
Factor XIa converts factor IX to factor IXa.
Factor XII, prekallikrein, and HMW kininogen are the contact
proteins(glass or kaolin).
IXa factor activate X to Xa, Xa activate prothrombin to thrombin,
thrombin convert fibrinogen into fibrin.
Activated Partial Thromboplastin Time
Used to detect inherited and acquired factor deficiency of the
intrinsic pathway, to screen for the lupus anticoagulant, and to
monitor heparin therapy.
Is an assay of the intrinsic and common pathway
A platelet substitute (phospholipid) and a surface-activating
agent such as micronized silica (to activate factor XII) are
added to platelet poor plasma (contact activation). Calcium is
added, and the clotting time is recorded.
Measures all the factors except VII and XIII
Reference values: 25-45 seconds
APTT
PT:
Used to screen for inherited or acquired abnormalities in the extrinsic (factor
VII) and common (factors V and X, prothrombin, and fibrinogen) pathways.
Clotting is initiated by commercial tissue factor reagent (thromboplastin that
contains phospholipids), which is mixed with Calcium and the clotting time is
determined.
Useful in determine Vitamin K dependent factors( prothrombin, factor VII,
factor X)
Normal ranges: 10-16 seconds
Increased PT usually indicates decreased synthesis of Vitamin K dependent
factors, factor V and fibrinogen concentrations or antibodies against
prothrombin and factor V or disfibrinogenemia.
Decrease PT result may be due to poor quality venipuncture
FIBRINOLYSIS
Lysis of the fibrin clot
Thrombin stimulates secretion of vascular endothelial cell
tissue plasminogen activator (t-PA).
Plasminogen and t-PA diffuse within the thrombus
t-PA activates plasminogen to plasmin,(protease capable of
degrading fibrin ) restricted to the clot
inhibitors to t-PA, plasmin are present in blood ( plasminogen
activator inhibitor, alpha2-antiplasmin)
Coagulation Factors measured by aPTT and PT assays
Causes for prolonged PT and or aPTT
Criteria for rejection of coagulation testing specimens
Specimen not labelled properly
Specimen missing patient identification
Sample spilled or the tube broken
Illegible test request form
Haemolysed sample
A clot in the sample
Inadequately filled tube
Specimens received more than 4 hours after collection
Hematocrit over 55% and not adjusted for a high hematocrit
Frozen whole blood sample
Overfilled tube
Common collection and handling problems
that affect coagulation test results
Reference intervals
Critical values
FDP
Principle:
This assay detects the presence of circulating fragments of fibrin degradation
products (FDPs) such as fibrinogen and soluble (non-cross linked) fibrin that are
produced by the action of plasmin.
Plasmin acts on these 2 substrates similarly, producing an initial cleavage product
called fragment X.
Plasmin then acts on fragment X, cleaving it into a transient fragment Y, and
fragment D.
Further cleavage of fragment Y, produces the terminal fibrin(ogen) degradation
products, fragment D and E.
Thus from one molecule of fibrinogen or soluble fibrin, 2 terminal FDP fragments D
and one terminal fragment E is produced.
The mean normal serum FDP is 4.9 ± 2.8 µg/ml
The results should never be interpreted alone, without evaluation of clinical signs
and results of other coagulation tests
D-dimer The D-dimer test measures the amount of a protein called “fibrin D-dimer” in the
blood.
Fibrin D-dimer is produced whenever fibrin is being actively degraded somewhere
within the vascular system.
This second process, which limits the growth of a forming blood clot, is mediated by
a protein called plasmin. Plasmin degrades the edges of the growing blood clot to
make sure it stays just the right size.
The amount of D-dimer found in the blood reflects the amount of active blood clot
formation that is occurring in the body.
An elevated blood level of D-dimer indicates that active blood clotting is taking
place.
A positive D-dimer result may indicate the presence of an abnormally high level of
fibrin degradation products. It indicates that there may be significant blood clot
(thrombus) formation and breakdown in the body.
MIXING STUDIES
Specific inhibitors of clotting factors may prolong aPTT (most common factor VIII)
Prolonged aPTT of unknown cases should be evaluated by mixing studies
Thrombin Time assay
Used to screen for abnormalities in the conversion of fibrinogen to fibrin
The addition of thrombin to plasma converts fibrinogen to fibrin bypassing
the intrinsic and extrinsic pathway. The time for fibrinogen to clot is a
function of fibrinogen concentration.
Thrombin is added to the patient’s plasma and the clotting time measured.
Reference range: 15-20 seconds
Common causes of prolonged time: fibrinogen deficiency, heparin, elevated
FDP, hyperfibrinogemia
High concentrations of thrombin result in shorter clotting time.
Platelet count assay
Part of the routine complete CBC
Normal ranges: 150-440 x 10^3/mm^3
Bleeding disorders caused by thrombocytopenia or thrombocytosis should
be evaluated by a bone marrow examination.
Bleeding Time assay
Used to screen inherited platelet dysfunction
Measures bleeding cessation from a small, superficial wound made under
standardized conditions
The Ivy bleeding time is the preferred method: a blood pressure cuff is
placed around the patient’s upper arm and the pressure is raised to
40mmHg. Two small punctures are made along the volar surface of the
patient’s forearm. The drops of blood issuing from the bleeding points are
absorbed at intervals of 30 seconds into 2 filter paper disks- one for each
puncture wound until bleeding ceases. The average of the times required
for bleeding to stop is taken as the bleeding time.
Normal value: <8 minutes
Ivy bleeding time vs. automated analyzers
Thrombocytopenia
Causes:
1.failure of bone marrow
reduced megakaryocytes, marrow infiltration with
tumor, infection, or fibrosis, marrow aplasia,
congenital abnormalities, ineffective
megakaryopoiesis, megaloblastic anemia,
myelodisplasia, alcohol suppression
2.increased platelet destruction
immune thrombocytopenia, autoantibody mediated
alloantibody mediated, non immune thrombocytopenia,
3.splenic sequestration
4.hemodilution
5.spurious
6.EDTA-pseudothrombocytopenia
Laboratory Tests for thrombocytopenia
Bleeding time: should be prolonged
PT and aPTT: normal results, exclude DIC
Platelet aggregation studies: should not be performed routinely unless an
inherited disorder is suspected
Heparin-induced thrombocytopenia: may occur as a complication of
heparin therapy; thrombocytopenia may occur after only 2 days in patients
who have received heparin therapy previously; positive when there is more
than 20% release at 0.1U/ml of heparin and less than 20% release at
100U/ml of heparin.
Platelet-associated immunoglobulin: measures IgG and IgM bound to the
patient’s platelets; the results are reported as the number of immunoglobulin
molecules per platelet.
Tests for TTP: is a disorder of vWF protease(ADAMTS-13); patients of TTP
has levels of <5-10U/ml.
Platelet aggregation studies
Qualitative Platelet disorders
Main groups: Bernard Soulier syndrome, Glanzmann’s thrombasthenia,
thrombopathies.
Bernard Soulier syndrome: failure of platelets to aggregate with ristocetin,
aggregation is normal with ADP, epinephrine, collagen and thrombin. Similar
to von Willebrand. Platelets are large; mild thrombocytopenia. Defect:
abnormal membrane glycoprotein(GPIb-V-IX). Inherited, autosomal
recessive, rare. Cd 42 deficiency is observed by flowcytometry.
Glanzmann’s thrombasthenia: no aggregation of ADP, epinephrine, or
collagen; however aggregation with ristocetin is normal. Defect in
glycoprotein IIb-IIIa. Associated with severe bleeding, inherited, autosomal
recessive. Deficiency of Cd41/Cd61.
Thrombopathies : abnormalities in the release reaction.
Divided in 2 subgroups: storage pool disease(deficiency of the specialized
pool of ADP) and defects in the mechanism responsible for the release of
the storage pool contents
Both are characterized by the absence of a secondary wave of
aggregation with epinephrine or ADP, aggregation with ristocetin is
normal.
In storage pool disease, there is a decrease in dense granules.
In the second group, the dense granules appear normal, but fail to release
their constituents when platelets are exposed to ADP, ephinephrine or
collagen. This is the most frequently encountered type in aspirin ingestion
Defects of platelet function
Laboratory tests for common bleeding disorders
Primarily on plasma (anticoagulated Na citrate 3.2-3.8%, 9:1
blood/sample ratio, plastic tubes)
Acquired coagulation disorders
Causes: decreased or abnormal synthesis of clotting factors caused by
liver disease or DIC, vitamin k deficiency, lupus anticoagulant, antibodies
to PT, factor V, VIII, XIII.
Liver disease and Vitamin K deficiency: the liver is the major site of clotting
factor synthesis. Hemorrage occurs in hepatitis and cirrhosis. Vitamin K-
dependent procoagulant factors and anticoagulant proteins(protein C, S),
are reduced.
Von Willebrand’s factor is elevated in liver disease. Fibrinolysis may be
enhanced in liver disease.
Coagulopathy of liver disease is complex and affects platelets, coagulation
and fibrinolysis.
Inherited Thrombotic Disorders
Thrombosis: formation a blood clot in the circulatory system during life.
Arterial thrombi: thrombi in the smallest vessels composed of platelets
Venous thrombi: thrombi of fibrin in vessels
Abnormalities of the protein C pathway, protein S, APC resistance,
thrombomodulin constitute half of all cases of inherited thrombosis.
Inherited thrombosis are transmitted in an autosomal dominant manner
and venous thromboembolism is the most common.
Homocysteinemia is found associated with thrombosis.
Risk factor: elevated factor VIII , IX, XI
Body fluids are one of the unique specimens received in the lab that
require multidisciplinary testing.
The types of fluids most commonly examined in hematology are
cerebrospinal (CSF), serous (pleural and peritoneal) and synovial.
Cerebral Spinal Fluid
CSF is normally a clear, colorless fluid which circulates around the brain and spinal
cord, providing a protective cushion for the delicate tissues.
This cushion is more chemical than physical in nature.
The CSF protects the brain and central nervous system from sudden changes in
pressure and pH, maintains a stable chemical environment, supplies nutrients and
removes metabolic waste products.
The total volume of CSF present is 90-150 mL in adults and 10-60 mL in neonates.
CSF is a dynamic and constantly changing fluid.
Laboratory findings can certainly vary accordingly in the presence of disease.
There are four legitimate reasons, or categories of disease, which warrant the
examination of CSF.
* suspected meningitis
* detection of subarachnoid hemorrhage
* detection of central nervous system (CNS) malignancy/leukemia
* diagnosis of demyelinating disease
Serous Fluids
Serous fluids include both pleural and peritoneal fluids.
The pleura and peritoneum are thin, double-layered membranes that surround the lungs and the abdominal/pelvic organs respectively.
The space between these membranes forms the pleural and peritoneal cavities which are lined by a single layer of mesothelial cells.
Normally, there is just enough fluid between the two membranes to provide lubrication.
The normal adult has just 5-15 mL of pleural fluid and less than 50 mL of peritoneal fluid.
Thus, these are potential cavities and become true cavities only in the presence of diseases which cause an accumulation of fluid.
Common causes of a pleural effusion are congestive heart failure, infection and malignancy.
Alcoholic cirrhosis is the most common cause of ascites.
Pleural and peritoneal effusions are traditionally separated into transudates and exudates for diagnostic purposes.
Fluids
Remind
transudate exudate
ph 7.4-7.5 7.35-7.45
Specific gravity <1.016 >1.016
erythrocytes few variable
leukocytes <1,000 >1,000
glucose equal to serum decreased
protein <3.0 g/dl >3.0 g/dl
pleural fluid serum protein <0.5 >0.5 g/dl
Ldh level <200 >200
pleural fluid LDH <2.3 >2.3 g/dl
congestive heart failure infectious disease
cirrhosis with ascites lymphoma
rheumatoid arthritis
Synovial Fluid
Synovial fluid is an ultrafiltrate of plasma combined with a hyaluronate-protein
complex produced by the lining cells of the synovial membrane.
The complex is responsible for the thick and gooey nature of synovial fluid
and makes it an excellent lubricant.
Synovial fluid not only lubricates the joint space, but also provides nutrients to
the cartilage.
Inflammatory joint diseases cause depolymerization of the hyaluronate-protein
complex and a resulting decrease in lubricating ability.
Examination of synovial fluid is usually performed to:
* detect sepsis
* detect a hemorrhage
* diagnose crystal induced
inflammation
A thoracentesis was performed on a 64-year-old male with nephrotic syndrome. Identify the cell:
A)Lymphocyte
B)Malignant cell
C)Mesothelial cell
D)Monocyte
The correct answer is B
This is a pleural fluid, identify the cell type at the end of the arrow.
a)Lymphocyte
b) Malignant Cell
c)Mesothelial Cell
d)Monocyte
The correct answer is C
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